For a patient in cardiogenic shock, the physician has ordered an intravenous continuous infusion of dobutamine hydrochloride. What nursing assessment result demonstrates achievement of therapeutic goals?
A) Blood pressure 120/70 mm Hg
B) Urine output 30 to 40 mL/hr
C) Arterial oxygen saturation 60%
D) Heart rate 110 to 120 bpm
B
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The nurse is concerned that an older client exhibits lethargy and headache. What other assessments does the nurse perform immediately? Select all that apply.
1. Mental status 2. Orthostatic blood pressure 3. Daily weight 4. Long tongue furrows 5. Forearm tenting of the skin
The nurse is preparing to insert a nasogastric tube in a patient who is semiconscious. To determine the length of the tube needed to be inserted, the nurse measures from the
a. Tip of the nose to the xiphoid process of the sternum. b. Earlobe to the xiphoid process of the sternum. c. Tip of the nose to the earlobe. d. Tip of the nose to the earlobe to the xiph-oid process.
A pregnant woman in her second trimester tells the nurse, "I've been passing a lot of gas and feel bloated." Which of the following suggestions would be helpful for the woman?
A) "Watch how much beans and onions you eat." B) "Limit the amount of fluid you drink with meals" C) "Try exercising a little more." D) "Some say that eating mints can help." E) "Cut down on your intake of cheeses."
The nurse manager observes care being provided by a graduate nurse who is caring for a client undergoing a forceps delivery. Which action requires intervention?
1. Bladder is emptied using a straight catheter. 2. The client is instructed to push between contractions. 3. Fetal heart tones are consistently between 110 and 115. 4. Regional anesthesia is administered via pudendal block.